Tenecteplase in Practice: A Rural Tele-Stroke Network’s Experience

Alteplase (tPA) and Tenecteplase (TNK) are both FDA-approved thrombolytic agents for acute ischemic stroke (AIS) treatment. While TNK showed efficacy and safety in the randomized clinical trials, its real-world utilization and effectiveness in rural populations remain key areas for post-approval evaluation. In August 2023 our academic institution, serving as a statewide telestroke network hub, implemented a system-wide transition from tPA to TNK. This study explores the real-world experience of this transition within a telestroke network in rural South Carolina. This retrospective study analyzed data from the Medical University of South Carolina (MUSC) Telestroke Network (1 Hub, 16 spoke centers) on patients with confirmed AIS who received thrombolytics between 2022 and 2024. We compared outcomes between patients treated with tPA or TNK and performed subgroup analyses for LVO and spoke center patients. The analysis focused on safety, efficiency metrics, and functional outcomes. Categorical and continuous variables were assessed using Fisher's exact and Wilcoxon rank-sum tests (p<0.05). Among 1644 patients with discharge diagnosis of AIS, 302 (18%) received thrombolytics: TNK (n=144, 47.7%) and tPA (n=158, 52.3%). Median door-to-needle times were similar (TNK 45 min vs. tPA 42 min, p=0.6). No statistical differences were observed in symptomatic hemorrhage (4.2% vs. 1.9%, p=0.32), discharge NIHSS, or hospital length of stay. Outcomes at spoke centers were comparable. In LVO transferred patients and treated at the hub, TNK was associated with fewer mechanical thrombectomy passes (median 1 vs. 2, p=0.046) and higher rates of functional independence at discharge (mRS ≤3: 75.4% vs. 54.4%, p=0.02). The system-wide transition to TNK resulted in similar safety profiles and treatment times, with notable improvements in procedural efficiency and functional outcomes for patients with LVO. These findings support the broader adoption of TNK as a viable alternative to tPA in acute ischemic stroke management, particularly in telestroke networks and rural communities where staffing and infrastructure may be constrained.